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Arab Board Neurosurgery Final Clinical & Oral study materials
Arab Board Neurosurgery Final Clinical & Oral study resources

Arab Board Neurosurgery Final Clinical & Oral practice questions

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Question 1Neuroanatomy and Neurophysiology (applied to clinical practice)

A patient has a lesion of the left optic tract. Which visual field defect is expected?

  1. Left homonymous hemianopia
  2. Bitemporal hemianopia
  3. Binasal hemianopia
  4. Right homonymous hemianopia Correct answer.

Explanation

The optic tract carries crossed nasal fibers from the contralateral eye and uncrossed temporal fibers from the ipsilateral eye, both subserving the contralateral visual field. A left tract lesion therefore produces a right homonymous hemianopia. Lesions behind the chiasm always produce homonymous defects on the side opposite the lesion.

Question 2Neuroanatomy and Neurophysiology (applied to clinical practice)

During a retrosigmoid approach, which cranial nerve is most at risk as it exits at the pontomedullary junction anterior to the flocculus?

  1. Abducens nerve
  2. Facial nerve Correct answer.
  3. Trochlear nerve
  4. Glossopharyngeal nerve

Explanation

The facial nerve exits the brainstem at the pontomedullary junction and courses through the cerebellopontine angle, where it is vulnerable during retrosigmoid exposure. Its close relationship to the vestibulocochlear nerve makes it the key structure to preserve in this corridor.

Question 3Neuroanatomy and Neurophysiology (applied to clinical practice)

A 55-year-old develops sudden right hemiparesis with expressive aphasia after surgery. Which vascular territory is most likely involved?

  1. Left anterior cerebral artery
  2. Right middle cerebral artery
  3. Left posterior cerebral artery
  4. Left middle cerebral artery Correct answer.

Explanation

The dominant (usually left) middle cerebral artery supplies the lateral frontal and parietal cortex, including Broca area and the motor strip. Occlusion produces contralateral face and arm weakness with expressive aphasia. The leg is relatively spared compared with anterior cerebral artery infarction.

Question 4Neuroanatomy and Neurophysiology (applied to clinical practice)

A patient cannot abduct the right eye and has horizontal diplopia worse on right gaze, with a normal pupil. Which nerve is affected?

  1. Right trochlear nerve
  2. Right abducens nerve Correct answer.
  3. Left abducens nerve
  4. Right oculomotor nerve

Explanation

The abducens nerve innervates the ipsilateral lateral rectus, so a right abducens palsy impairs abduction of the right eye. The pupil is spared because the abducens nerve carries no pupillomotor fibers, unlike the oculomotor nerve.

Question 5Neuroanatomy and Neurophysiology (applied to clinical practice)

Which structure marks the boundary between the frontal horn and the body of the lateral ventricle?

  1. Septum pellucidum
  2. Thalamus
  3. Corpus callosum
  4. Foramen of Monro Correct answer.

Explanation

The foramen of Monro (interventricular foramen) is the landmark separating the frontal horn from the body of the lateral ventricle. It connects the lateral ventricle to the third ventricle and is bounded by the fornix anteriorly and the thalamus posteriorly.

Question 6Neuroanatomy and Neurophysiology (applied to clinical practice)

A lesion of the left cerebellar hemisphere is most likely to produce which finding?

  1. Bilateral resting tremor
  2. Left-sided intention tremor and dysmetria Correct answer.
  3. Right-sided intention tremor and dysmetria
  4. Contralateral hemiparesis

Explanation

The cerebellar hemispheres project to the ipsilateral motor cortex via the dentatothalamocortical pathway, so hemispheric lesions produce ipsilateral limb ataxia. Intention tremor and dysmetria occur on the same side as the lesion. Resting tremor and weakness are features of basal ganglia and corticospinal lesions, respectively.

Question 7Neuroanatomy and Neurophysiology (applied to clinical practice)

A patient has loss of pain and temperature sensation over the left face and right body with a left Horner syndrome. Where is the lesion?

  1. Left lateral medulla Correct answer.
  2. Right lateral medulla
  3. Right dorsal midbrain
  4. Left ventral pons

Explanation

This is Wallenberg syndrome from occlusion of the left posterior inferior cerebellar artery or vertebral artery. The left spinal trigeminal nucleus and tract loss gives ipsilateral facial pain/temperature loss, the left spinothalamic tract loss gives contralateral body loss, and descending sympathetic fibers produce ipsilateral Horner syndrome.

Question 8Neuroanatomy and Neurophysiology (applied to clinical practice)

Which nerve is most commonly injured during carotid endarterectomy because it crosses superficial to the carotid bifurcation?

  1. Recurrent laryngeal nerve
  2. Vagus nerve
  3. Greater auricular nerve Correct answer.
  4. Hypoglossal nerve

Explanation

The greater auricular nerve lies superficial in the neck and crosses the carotid bifurcation, making it vulnerable during dissection and retraction. Injury causes numbness of the ear lobe and angle of the mandible. The hypoglossal and vagus nerves are deeper and injured less commonly.

Question 9Neuroanatomy and Neurophysiology (applied to clinical practice)

Which thalamic nucleus relays somatosensory information from the contralateral body to the primary somatosensory cortex?

  1. Mediodorsal nucleus
  2. Anterior nucleus
  3. Ventroposteromedial nucleus
  4. Ventroposterolateral nucleus Correct answer.

Explanation

The ventroposterolateral (VPL) nucleus receives the medial lemniscus and spinothalamic projections from the contralateral body and projects to the postcentral gyrus. Facial sensation is relayed via the adjacent ventroposteromedial nucleus. This topographic separation explains the dissociated sensory loss in thalamic lesions.

Question 10Neuroanatomy and Neurophysiology (applied to clinical practice)

A patient has a complete spinal cord transection at T4. Which function is most likely preserved?

  1. Voluntary bowel control
  2. Diaphragmatic breathing Correct answer.
  3. Lower limb proprioception
  4. Sacral sensation

Explanation

The phrenic nucleus lies at C3-C5, above a T4 lesion, so diaphragmatic respiration is preserved. All functions mediated below the lesion, including sacral sensation, lower limb proprioception, and voluntary bowel control, are lost in a complete transection.

Question 11Neuroimaging and Diagnostic Investigations

On a non-contrast CT scan of the head, acute intraparenchymal haemorrhage typically appears as which of the following?

  1. Hypodense relative to brain parenchyma
  2. Isointense on T1-weighted MRI
  3. Hyperdense relative to brain parenchyma Correct answer.
  4. Isodense with a low-density rim

Explanation

Fresh blood clot has high attenuation on CT because of the concentrated haemoglobin and protein content, so acute haemorrhage appears hyperdense (roughly 50-90 HU) against normal brain. Density falls over days to weeks as the clot degrades, eventually becoming hypodense.

Question 12Neuroimaging and Diagnostic Investigations

Which MRI sequence is most sensitive for detecting acute subarachnoid haemorrhage when CT is negative several days after the ictus?

  1. GRE/SWI
  2. FLAIR Correct answer.
  3. T2-weighted
  4. T1-weighted

Explanation

FLAIR suppresses CSF signal but not blood products, so subarachnoid blood appears as high signal in the sulci and cisterns even after CT sensitivity falls. It is particularly useful in the subacute window when CT may be negative.

Question 13Neuroimaging and Diagnostic Investigations

A patient has a suspected pituitary macroadenoma. Which imaging study best defines the relationship of the tumour to the cavernous sinus and internal carotid artery?

  1. Carotid Doppler ultrasound
  2. Non-contrast CT of the head
  3. Plain skull radiograph
  4. MRI of the pituitary with thin-slice contrast-enhanced sequences Correct answer.

Explanation

Dedicated pituitary MRI with thin slices and dynamic contrast enhancement delineates the tumour, cavernous sinus invasion and the relationship to the internal carotid arteries, which is essential for surgical planning. CT and ultrasound cannot resolve these soft-tissue relationships.

Question 14Neuroimaging and Diagnostic Investigations

In the assessment of a cerebral arteriovenous malformation, which feature on catheter angiography most strongly predicts the risk of haemorrhage?

  1. Presence of intranidal or feeding-artery aneurysms Correct answer.
  2. Number of feeding arteries
  3. Location within the frontal lobe
  4. Diameter of the largest draining vein

Explanation

Intranidal and flow-related feeding-artery aneurysms are among the strongest angiographic predictors of haemorrhage in AVMs. Venous stenosis and deep venous drainage also raise risk, but simple vein diameter or feeder number alone are weaker predictors.

Question 15Neuroimaging and Diagnostic Investigations

Which finding on MRI is characteristic of a cerebral abscess cavity rather than a cystic tumour?

  1. A calcified rim with no enhancement
  2. A thick irregular enhancing rim with central high T2 signal
  3. A thin, smooth enhancing rim with restricted diffusion centrally Correct answer.
  4. A homogeneous non-enhancing cyst with CSF-like signal

Explanation

Abscess pus restricts diffusion, giving high signal on DWI and low ADC, and the capsule typically enhances as a thin smooth rim. This combination distinguishes abscess from necrotic tumour, which usually shows facilitated rather than restricted central diffusion.

Question 16Neuroimaging and Diagnostic Investigations

A patient presents with sudden severe headache and CT shows diffuse subarachnoid blood. Which investigation is the next most appropriate to identify a causative aneurysm?

  1. Repeat non-contrast CT in 24 hours
  2. Skull radiograph
  3. Lumbar puncture
  4. CT angiography of the intracranial circulation Correct answer.

Explanation

When subarachnoid haemorrhage is confirmed on CT, CT angiography is the appropriate next step to localise an aneurysm and guide treatment. Catheter angiography is reserved for cases where CTA is inconclusive or for planning complex interventions.

Question 17Neuroimaging and Diagnostic Investigations

On diffusion-weighted imaging, which condition produces restricted diffusion with a low apparent diffusion coefficient?

  1. Enlarged perivascular spaces
  2. Vasogenic oedema surrounding a metastasis
  3. Acute ischaemic infarction Correct answer.
  4. Chronic white matter demyelination

Explanation

Acute infarction causes cytotoxic oedema with restricted water diffusion, appearing bright on DWI and dark on the ADC map. Vasogenic oedema and chronic lesions increase extracellular water and show facilitated diffusion (high ADC).

Question 18Neuroimaging and Diagnostic Investigations

Which imaging modality is the investigation of choice for suspected acute cervical spine injury in an obtunded adult after blunt trauma?

  1. Flexion-extension radiographs
  2. Plain lateral cervical radiograph
  3. MRI of the cervical spine
  4. CT of the cervical spine with sagittal and coronal reconstructions Correct answer.

Explanation

CT with multiplanar reconstruction is the standard first-line study for acute cervical trauma because of its high sensitivity for fracture and rapid acquisition. MRI is added when ligamentous or cord injury is suspected and the patient can be safely scanned.

Question 19Neuroimaging and Diagnostic Investigations

A patient with a known vestibular schwannoma is being assessed for microsurgery. Which MRI feature best predicts adherence of the tumour to the facial nerve?

  1. Presence of a cystic component
  2. Tumour hyperintensity on T2-weighted images
  3. Loss of the cerebrospinal fluid cleft at the fundus of the internal auditory canal Correct answer.
  4. Size greater than 2 cm

Explanation

Loss of the CSF plane at the fundus (the fundal fluid cap) suggests the tumour fills the canal and abuts the nerve, which correlates with greater difficulty in preserving the facial nerve. Tumour size and cystic change influence overall risk but are weaker predictors of nerve adherence.

Question 20Neuroimaging and Diagnostic Investigations

Which radiological finding on CT is most suggestive of a chronic subdural haematoma?

  1. A biconvex hyperdense collection crossing the midline
  2. A crescentic collection with mixed density and a smooth inner margin Correct answer.
  3. A small hyperdense focus at the grey-white junction
  4. Diffuse loss of grey-white differentiation

Explanation

Chronic subdural haematomas appear as crescentic collections that may be hypodense, isodense or mixed density, often with membrane formation and a smooth inner margin. Their shape follows the convexity rather than being constrained by sutures.

Question 21Neuroimaging and Diagnostic Investigations

A patient with a suspected cerebral aneurysm has a negative CT angiogram but clinical features remain strongly suggestive. Which study provides the highest spatial resolution for detecting a small aneurysm?

  1. MR angiography without contrast
  2. CT perfusion
  3. Transcranial Doppler
  4. Digital subtraction catheter angiography Correct answer.

Explanation

Catheter digital subtraction angiography remains the reference standard for detecting small aneurysms and defining vascular anatomy, with spatial resolution superior to non-invasive techniques. It is used when CTA or MRA is negative but suspicion persists.

Question 22Neuroimaging and Diagnostic Investigations

Which imaging finding on MRI best distinguishes an epidermoid cyst from an arachnoid cyst in the cerebellopontine angle?

  1. Restricted diffusion on DWI Correct answer.
  2. Displacement of the brainstem
  3. High T2 signal content
  4. Absence of contrast enhancement

Explanation

Epidermoid cysts contain keratinaceous debris that restricts diffusion, appearing bright on DWI and low on ADC, whereas arachnoid cysts follow CSF and do not restrict. This is the most reliable discriminator between the two.

Question 23Neuroimaging and Diagnostic Investigations

On CT, which feature most reliably distinguishes an epidural haematoma from a subdural haematoma?

  1. Presence of midline shift
  2. Biconvex shape limited by suture lines Correct answer.
  3. Crescentic shape crossing suture lines
  4. Association with skull fracture

Explanation

Epidural haematomas arise between skull and dura and are constrained by cranial sutures, producing a biconvex (lens-shaped) collection. Subdural haematomas spread in the subdural space and are crescentic, crossing sutures but not dural attachments.

Question 24Neuroimaging and Diagnostic Investigations

A patient with a suspected spinal dural arteriovenous fistula undergoes MRI. Which finding is most characteristic?

  1. Enlarged perimedullary veins with cord oedema on T2-weighted images Correct answer.
  2. A well-defined intramedullary mass with homogeneous enhancement
  3. A syrinx cavity with no flow voids
  4. Multilevel disc degeneration with nerve root compression

Explanation

Spinal dural arteriovenous fistulas cause venous congestion, producing swollen, T2-hyperintense cord with prominent flow voids of dilated perimedullary veins. Catheter spinal angiography confirms the fistula and its feeding artery.

Question 25Neuroimaging and Diagnostic Investigations

Which technique is most appropriate for confirming brain death in a patient with an absent acoustic and oculovestibular response but confounding sedation?

  1. Carotid Doppler of the neck
  2. EEG during sedation
  3. Four-vessel catheter cerebral angiography Correct answer.
  4. Non-contrast CT of the head

Explanation

Four-vessel cerebral angiography demonstrating absent intracranial flow is an accepted confirmatory test for brain death when clinical assessment is confounded. Ancillary tests are used according to local protocol and must be interpreted with the clinical context.

Question 26Neuroimaging and Diagnostic Investigations

On MRI, which feature best suggests a high-grade glioma rather than a low-grade glioma?

  1. Ring enhancement with central necrosis and elevated choline on MR spectroscopy Correct answer.
  2. Homogeneous signal with no enhancement
  3. Well-circumscribed margins and no surrounding oedema
  4. Calcification on T2-weighted images

Explanation

Ring enhancement with central necrosis and raised choline with reduced N-acetylaspartate indicate high-grade biology. Low-grade gliomas tend to be non-enhancing and homogeneous, though imaging alone cannot definitively grade a tumour.

Question 27Neurotrauma (cranial and spinal)

A 28-year-old man with a Glasgow Coma Scale score of 6 after a road traffic collision has a CT scan showing a 4 mm acute subdural haematoma with no midline shift and patent basal cisterns. He is haemodynamically stable and not on anticoagulants. What is the most appropriate initial management?

  1. Observation with repeat CT and neurological checks Correct answer.
  2. Insertion of an external ventricular drain
  3. Urgent craniotomy and evacuation
  4. Admission to ICU with intracranial pressure monitoring

Explanation

Small acute subdural haematomas without mass effect, midline shift or cisternal effacement in a stable patient are managed conservatively with serial neurological assessment and repeat imaging. Surgery is reserved for significant thickness, mass effect or clinical deterioration. An EVD or ICP monitor is not indicated without evidence of raised ICP or hydrocephalus.

Question 28Neurotrauma (cranial and spinal)

Which finding on CT most strongly predicts the need for surgical evacuation in an acute epidural haematoma?

  1. Presence of a skull fracture
  2. Headache with vomiting
  3. Thickness greater than 15 mm Correct answer.
  4. A lucid interval before deterioration

Explanation

Guidelines use haematoma volume or thickness (commonly greater than 15 mm), midline shift greater than 5 mm, and clinical signs of herniation as indications for evacuation of an epidural haematoma. Skull fracture and a lucid interval are associated features but are not the primary size criterion.

Question 29Neurotrauma (cranial and spinal)

A patient with a severe traumatic brain injury has a ventricular drain in place for intracranial pressure monitoring. Which intracranial pressure threshold is most widely used to trigger tiered escalation of therapy?

  1. 22 mmHg Correct answer.
  2. 35 mmHg
  3. 15 mmHg
  4. 10 mmHg

Explanation

Consensus guidelines recommend treating intracranial pressure sustained above 22 mmHg, since values above this threshold are associated with worse outcome. Lower values such as 10 to 15 mmHg are within the normal range, and 35 mmHg represents a severe crisis rather than the treatment trigger.

Question 30Neurotrauma (cranial and spinal)

Which cerebral perfusion pressure target is recommended for most adults with severe traumatic brain injury?

  1. 80 to 90 mmHg
  2. 100 to 110 mmHg
  3. 50 to 60 mmHg
  4. 60 to 70 mmHg Correct answer.

Explanation

Current guidelines recommend a cerebral perfusion pressure target of 60 to 70 mmHg in adults with severe traumatic brain injury. Higher targets increase the risk of acute respiratory distress syndrome without proven neurological benefit, and lower targets risk cerebral ischaemia.

Question 31Neurotrauma (cranial and spinal)

A 45-year-old unrestrained driver has a C6 flexion-distraction injury with bilateral facet dislocation and an incomplete spinal cord injury. He is haemodynamically stable with no other life-threatening injuries. What is the most appropriate early management?

  1. Steroid infusion as definitive treatment
  2. Six weeks of rigid collar immobilisation alone
  3. Immediate laminectomy without reduction
  4. Closed reduction with traction followed by MRI and surgical stabilisation Correct answer.

Explanation

Bilateral facet dislocation is an unstable injury that should be reduced urgently, often by closed traction in a stable patient, followed by MRI to assess disc herniation and then surgical stabilisation. Laminectomy alone does not reduce the dislocation and may worsen instability. Steroids are not definitive treatment.

Question 32Neurotrauma (cranial and spinal)

Which clinical feature best distinguishes a complete spinal cord injury from an incomplete one in the acute setting?

  1. Absence of sacral sparing Correct answer.
  2. Presence of a bulbocavernosus reflex
  3. Presence of spinal shock
  4. Priapism

Explanation

Sacral sparing, meaning preserved perianal sensation, voluntary anal contraction or deep anal pressure, defines an incomplete injury. Its absence in the acute phase indicates a complete injury. Spinal shock and the bulbocavernosus reflex relate to timing of reflex return, not completeness.

Question 33Neurotrauma (cranial and spinal)

A patient with a traumatic brain injury has a CT scan showing a small frontal contusion and a dilated right pupil with bradycardia and hypertension. What does this triad most likely indicate?

  1. Septic shock
  2. Spinal shock
  3. Neurogenic shock
  4. Cushing reflex from raised intracranial pressure Correct answer.

Explanation

Hypertension with bradycardia and irregular respiration, together with a dilated pupil, constitutes the Cushing reflex, indicating critically raised intracranial pressure and impending herniation. Neurogenic and spinal shock cause hypotension with bradycardia or areflexia, not this pattern.

Question 34Neurotrauma (cranial and spinal)

Which type of traumatic intracranial haematoma most commonly results from tearing of the bridging cortical veins?

  1. Epidural haematoma
  2. Contusion
  3. Diffuse axonal injury
  4. Acute subdural haematoma Correct answer.

Explanation

Acute subdural haematomas typically arise from tearing of bridging cortical veins as the brain moves relative to the skull. Epidural haematomas usually result from middle meningeal artery injury, and diffuse axonal injury results from shearing forces at the grey-white junction.

Question 35Neurotrauma (cranial and spinal)

A 30-year-old woman has a depressed skull fracture with a scalp laceration and visible brain tissue. Which management step is most appropriate?

  1. Irrigation, debridement and elevation of the fracture with dural repair in theatre Correct answer.
  2. Simple wound closure in the emergency department
  3. Immediate shunt placement
  4. Observation with antibiotics alone

Explanation

An open depressed skull fracture with exposed brain is a neurosurgical emergency requiring operative debridement, elevation of the depressed fragment and dural repair to prevent infection. Simple closure or antibiotics alone leave contaminated bone and dural defects untreated.

Question 36Neurotrauma (cranial and spinal)

Which finding on CT is characteristic of diffuse axonal injury?

  1. Crescentic extra-axial collection
  2. Biconvex hyperdense collection
  3. Punctate haemorrhages at the grey-white junction Correct answer.
  4. Enlarged ventricles with periventricular lucency

Explanation

Diffuse axonal injury produces small petechial haemorrhages at the grey-white matter junction, corpus callosum and brainstem due to shearing forces. Biconvex and crescentic collections describe epidural and subdural haematomas respectively.

Question 37Neurotrauma (cranial and spinal)

In the management of severe traumatic brain injury, which measure is recommended as first-tier therapy for raised intracranial pressure after sedation and analgesia are optimised?

  1. Hyperventilation to a PaCO2 of 25 mmHg
  2. Osmotherapy with mannitol or hypertonic saline Correct answer.
  3. Decompressive craniectomy
  4. Therapeutic hypothermia

Explanation

Osmotherapy with mannitol or hypertonic saline is a first-tier measure for raised intracranial pressure after optimising sedation, analgesia and CSF drainage. Decompressive craniectomy and therapeutic hypothermia are later-tier options, and aggressive hyperventilation is reserved for acute herniation because of ischaemia risk.

Question 38Neurotrauma (cranial and spinal)

A patient with a thoracic spinal fracture has a neurological level of T6 and develops hypotension with bradycardia. What is the most likely cause?

  1. Hypovolaemic shock from occult bleeding
  2. Cardiogenic shock
  3. Neurogenic shock from loss of sympathetic tone Correct answer.
  4. Septic shock

Explanation

Cervical and high thoracic cord injuries interrupt sympathetic outflow, producing neurogenic shock with hypotension and bradycardia from unopposed vagal tone. Hypovolaemic shock typically produces tachycardia, and cardiogenic or septic shock have different clinical features.

Question 39Neurotrauma (cranial and spinal)

Which imaging modality is most appropriate for detecting a ligamentous cervical spine injury in an awake, alert patient with neck pain after blunt trauma and a normal CT scan?

  1. MRI of the cervical spine Correct answer.
  2. Ultrasound of the neck
  3. Repeat CT in 24 hours
  4. Flexion-extension radiographs

Explanation

MRI is the most sensitive modality for ligamentous and soft tissue injury of the cervical spine and is used when CT is normal but clinical suspicion persists. Flexion-extension views have limited sensitivity in the acute setting, and ultrasound has no role.

Question 40Neurotrauma (cranial and spinal)

Which of the following is the most appropriate first step in the emergency management of a patient with a suspected cervical spine injury and airway compromise?

  1. Manual in-line stabilisation with jaw thrust and suction during intubation Correct answer.
  2. Blind nasotracheal intubation
  3. Cervical collar removal and direct laryngoscopy
  4. Awake fibreoptic intubation

Explanation

Airway management in suspected cervical injury requires manual in-line stabilisation to limit spinal movement, with suction and jaw thrust to maintain alignment. Blind nasal intubation is contraindicated in suspected basal skull fracture and carries trauma risk, and collar removal without stabilisation risks further injury.

Question 41Neurotrauma (cranial and spinal)

A patient with a traumatic brain injury develops diabetes insipidus with high urine output and rising serum sodium. Which structure is most likely injured?

  1. Pineal gland
  2. Hypothalamic median eminence
  3. Anterior pituitary
  4. Posterior pituitary Correct answer.

Explanation

Diabetes insipidus after head injury results from damage to the posterior pituitary or its stalk, impairing antidiuretic hormone release. The anterior pituitary produces different hormones and the pineal gland is unrelated to water balance.

Question 42Neurotrauma (cranial and spinal)

Which clinical sign suggests a basal skull fracture?

  1. Unilateral mydriasis
  2. Neck stiffness
  3. Positive Babinski sign
  4. Bilateral periorbital ecchymosis Correct answer.

Explanation

Bilateral periorbital ecchymosis, known as raccoon eyes, together with retroauricular ecchymosis and CSF rhinorrhoea or otorrhoea, suggests a basal skull fracture. Mydriasis suggests herniation, and Babinski sign indicates an upper motor neuron lesion.

Question 43Neurotrauma (cranial and spinal)

A patient with a severe traumatic brain injury is being considered for decompressive craniectomy. Which statement best reflects current evidence from randomised trials?

  1. It improves survival but may increase the proportion of survivors with severe disability Correct answer.
  2. It is the first-line treatment for any intracranial hypertension
  3. It has no effect on intracranial pressure
  4. It reliably improves functional outcome in all patients

Explanation

Randomised trials of decompressive craniectomy in severe traumatic brain injury show reduced mortality but a higher rate of survivors with severe disability compared with medical management. It does reduce intracranial pressure and is used for refractory hypertension rather than as first-line therapy.

Question 44Neurotrauma (cranial and spinal)

Which finding on CT indicates an unstable Jefferson (atlas) fracture?

  1. Isolated anterior arch fracture
  2. Presence of a cervical rib
  3. Overhang of the lateral masses of C1 on C2 greater than 7 mm in total Correct answer.
  4. Fracture of the spinous process of C7

Explanation

A total lateral mass overhang of more than 7 mm on the open-mouth odontoid view suggests disruption of the transverse ligament and an unstable burst fracture of C1. Isolated arch fractures without displacement and spinous process fractures are typically stable.

Question 45Neurotrauma (cranial and spinal)

A patient has a traumatic subarachnoid haemorrhage with hydrocephalus and reduced consciousness. What is the most appropriate initial intervention?

  1. Repeat CT in 48 hours
  2. Hypertonic saline infusion alone
  3. External ventricular drain insertion Correct answer.
  4. Lumbar puncture

Explanation

Traumatic subarachnoid haemorrhage can impair CSF absorption and cause hydrocephalus, which is managed with an external ventricular drain to divert CSF and monitor intracranial pressure. Lumbar puncture is contraindicated in the presence of raised intracranial pressure and mass effect.

Question 46Neurotrauma (cranial and spinal)

Which statement about post-traumatic seizures is correct?

  1. Early post-traumatic seizures occur within the first seven days after injury Correct answer.
  2. Prophylactic anticonvulsants reduce the incidence of late post-traumatic seizures
  3. Phenytoin is contraindicated in all head injuries
  4. Seizure prophylaxis should be continued for at least one year in all patients

Explanation

Early post-traumatic seizures are defined as occurring within seven days of injury. Prophylactic anticonvulsants reduce early seizures but do not prevent late epilepsy, and routine long-term prophylaxis is not recommended for all patients.

Question 47Neurotrauma (cranial and spinal)

A patient with a gunshot wound to the head has a CT showing a tangential injury with retained bone fragments and no mass lesion. Which factor most influences the decision for surgical debridement?

  1. Presence of intracranial air
  2. Patient age
  3. Neurological status and extent of contamination Correct answer.
  4. Time since injury under 24 hours

Explanation

Surgical debridement of penetrating head injury is guided by neurological status, the extent of contamination and the presence of mass effect or accessible fragments. Pneumocephalus and timing alone do not determine the need for surgery.

Question 48Neurotrauma (cranial and spinal)

Which clinical feature is most consistent with a central cord syndrome after a hyperextension injury in an elderly patient with cervical spondylosis?

  1. Isolated unilateral loss of pain and temperature sensation
  2. Greater weakness in the upper limbs than the lower limbs Correct answer.
  3. Greater weakness in the lower limbs than the upper limbs
  4. Complete loss of all motor and sensory function below the lesion

Explanation

Central cord syndrome characteristically produces greater motor deficit in the upper limbs than the lower limbs, with sacral sensory sparing. Complete loss below the lesion indicates a complete cord injury, and isolated pain and temperature loss suggests a Brown-Sequard or anterior cord pattern.

Question 49Neurotrauma (cranial and spinal)

Which of the following is the most reliable early indicator of raised intracranial pressure in an intubated and sedated patient with severe traumatic brain injury?

  1. Serial Glasgow Coma Scale scores
  2. Pupillary size
  3. Computed tomography findings alone
  4. Intracranial pressure waveform analysis Correct answer.

Explanation

In sedated and paralysed patients, clinical examination is unreliable, so intracranial pressure monitoring with waveform analysis provides the most direct and reliable indicator of raised pressure. Pupillary changes and CT findings are useful adjuncts but are less sensitive for early detection.

Question 50Neurotrauma (cranial and spinal)

A patient with a thoracic vertebral fracture has a normal neurological examination but CT shows greater than 50 percent loss of vertebral body height with kyphotic deformity. What is the most appropriate management consideration?

  1. Surgical stabilisation because of mechanical instability Correct answer.
  2. Immediate laminectomy
  3. Casting in a halo vest
  4. Discharge with analgesia alone

Explanation

Loss of more than 50 percent of vertebral body height with kyphosis indicates mechanical instability and generally warrants surgical stabilisation, particularly in the thoracolumbar region. A halo vest is used for cervical injuries, and laminectomy alone does not address anterior column instability.